Injuries, illness, and other medical conditions impact readiness. Commanders are faced with the daily challenge of controlling injuries in the conduct of rigorous military training. Leaders must be familiar with the factors that influence injury risk. Adherence to the fundamental principles of PRT allows the commander to manage injury risk effectively. When injuries, illness, or other medical conditions limit the Soldier’s ability to participate in PRT, units should offer organized and effective reconditioning programs that expedite his return to unit PRT.
Injuries are defined as any intentional or unintentional damage to the body resulting from acute or chronic exposure to mechanical, thermal, electrical, or chemical energy, and from the absence of such essentials as heat or oxygen. The information in this section will focus specifically on musculoskeletal (orthopedic) conditions, since they represent the type of injury risk most responsive to sound PRT practices. Among the other conclusions from the DoD Injury Work Group: In the Army alone, musculoskeletal conditions account for over half of all disabilities creating compensation of about $125 million per year. Knee and back injuries constitute a significant proportion of disability and limited duty. Training injuries treated on an outpatient basis and sports injuries may have the biggest impact on readiness.
According to the Atlas of Injuries in the Armed Forces:
"...injuries pose the single most significant medical impediment to readiness in the military. Not only do injuries impact the strength and ability of our Armed Forces to effectively respond to their mission, they levy staggering annual costs in the hundreds of millions of dollars against the operating budgets of all the services."
- DoD Injury Surveillance and Prevention Work Group (Injury Work Group)
The reconditioning program described in this FM responds to the DoD Injury Work Group recommendation to “…implement programs designed to enhance fitness and reduce training injury rates.” By enhancing the fitness level of Soldiers during the profile and post-profile recovery period, this program is expected to reduce training injury rates. The Army Physical Readiness Training System, shown in Figure 6-1, was developed with Soldier performance and injury control as its two primary objectives. Though these objectives may seem to oppose one another at first glance, the principles of PRT that improve Soldier performance also contribute to reducing injury risk. The DoD Injury Work Group recommends the following measures for injury prevention:
- Implement programs designed to enhance fitness and reduce training injury rates.
- Target knee and back injuries for additional efforts toward prevention.
- Place greater emphasis on prevention of training and sports injuries.
Figure 6-1. Army Physical Readiness Training System.
The Army PRT System shown in Figure 6-1 includes reconditioning as part of the toughening and sustaining phases for Soldiers to facilitate recovery from illness, injury, or other medical conditions. Soldiers in need of recovery should return to unit PRT at a level equal to or higher than their physical state previous to the condition that brought them to reconditioning. Commanders and NCOs must take an active role to control avoidable injuries; however, in spite of every effort to limit injuries in the Army, Soldiers and situations will continue to produce overuse, accidental, and/or traumatic injuries. Keeping this in mind, a plan to bridge the gap between injury and physical readiness is essential. Reconditioning bridges this gap.
"Injuries are not random events; they are the predictable result of a complex set of risk factors, many of which can and should be controlled."
- MG Patrick Scully, Deputy Surgeon General, U.S. Army (1998-2002)
COMMANDER'S ROLE IN INJURY CONTROL
Precise execution of all PRT activities is essential to the injury control effort. Commanders must allow trained PRT leaders and AIs the time to teach proper execution of PRT activities. PRT leaders and AIs must be able to recognize and offer corrective guidance to Soldiers who are not executing drills to the standards described in this FM. It is especially important for PRT leaders and AIs to maintain the standard since transition from the toughening to the sustaining phase of training depends on execution of the drills to standard. For example, to control back injuries, postural awareness should be stressed during execution of all drills and activities. This is evident when the PRT leader or the AI prompts Soldiers to “set the hips and tighten the abs” while performing the exercises.
Both military and civilian research has shown that reduced running volume is associated with lower injury rates. Accordingly, PRT schedules prescribed in this FM involve less sustained running than is currently performed in Army units. Several studies of military units have shown that reduced running volume does not hinder performance on two- or three-mile run assessments as long as the quality (intensity) of running is maintained.
In addition to using appropriate PRT schedules, units must also look for conflicts between the PRT schedule and the unit training schedule. By considering the physical demands of tasks on the unit training schedule, PRT leaders are better prepared to plan appropriate PRT sessions. For example, if a 10-km foot march to a range is scheduled for Friday, speed work should not be scheduled for PRT on Thursday. Time should be allotted for leg recovery. Monday and Wednesday’s PRT should not involve CLs 1 and 2 or the strength training circuit if Tuesday’s unit training schedule takes the unit to an obstacle course where upper body strength is heavily challenged.
EXECUTING UNIT RECONDITIONING PROGRAMS
The following paragraphs assist leaders as they plan and execute a reconditioning program within their units. Army Reserve and National Guard units may tailor this program to meet their specific requirements. The purpose of a reconditioning program is to safely restore a level of physical readiness that enables Soldiers to successfully re-enter unit PRT after injury, illness or other medical condition. A physical profile defines, in writing, limitations to physical activity due to injury, illness or medical condition. The authorized forms for written profiles in the Army are the DD Form 689 and DA Form 3349. DA Form 3349 is better than DD Form 689, because it requires a much more detailed description of the Soldier’s injury and the activities and exercises that the Soldier can perform with the injury. Soldiers assigned to the reconditioning program include:
- Soldiers on temporary medical profile.
- Soldiers in the recovery period after a temporary profile expires.
- Soldiers on permanent medical profile with specific limitations and special fitness requirements.
To address the needs of Soldiers who are on profile and those recovering from profile, reconditioning employs a two-level system. Level I is a gym-based program designed to maximize the potential of a profiled Soldier while protecting the injured area. Soldiers enter level I once cleared to begin limited activity by the profiling health care provider. Activities in level I include the use of STMs and ETMs. Functional criteria are used to determine whether a Soldier is able to begin reconditioning, at level I or level II.
To begin at level II, the profile or recovery reconditioning program, Soldiers must meet the level II reconditioning entry criteria requirements shown in Figure 6-2. Upon entering level II, Soldiers will begin to perform the PRT program. In this level the Soldier is on profile, just off of profile, or cleared to begin level II reconditioning. Preparation will be exactly the same as for unit PRT. The activity may be modified to follow a safe exercise progression. Recovery will be exactly the same as unit PRT.
|Partial Squats Without Pain
||5 Repetitions in 5 Seconds
||10 Repetitions to Standard
||10 Repetitions to Standard
|Hang From Pull-Up Bar
||30 Minutes Unassisted, at Normal Gait without Pain
Figure 6-2. Level II reconditioning entry criteria.
Before being discharged from level II and returning to unit PRT, Soldiers must meet the level II exit criteria requirements shown in Figure 6-3.
||5 Repetitions to Standard
|Military Movement Drill 1
||1 Repetition to Standard
|Conditioning Drill 1
||5 Repetitions to Standard
|Climbing Drill 1
||5 Repetitions to Standard
||30 Minutes at Slowest AGR Pace in Unit
||Hold Each Stretch for 20 Seconds To Standard
Figure 6-3. Level II exit criteria.
TOUGHENING PHASE RECONDITIONING
Rehabilitation and reconditioning programs within IMT are currently conducted at all Army Training Centers as a part of the physical training and rehabilitation program (PTRP). The purpose of the PTRP is to provide physical rehabilitation and physical conditioning for Soldiers who are injured during BCT or OSUT. These programs usually fall under the training command and act independently under the supervision of a physical therapist. Soldiers remain in the PTRP until they are capable of returning to the same phase of BCT/OSUT that they left or as a “new start” at day one of IMT. If an injury is minor and only requires shortterm limitations (with minimal impact to training); it may not require assignment to the PTRP.
SUSTAINING PHASE RECONDITIONING
Reconditioning in the sustaining phase includes AIT and operational units. Consolidation of reconditioning programs at the battalion (or equivalent) level minimizes the administrative and logistical strain on operational unit assets. The brigade surgeon should have medical oversight of the unit reconditioning program. Battalion medical officers are the liaisons between reconditioning program leaders (RPLs) and the brigade surgeon. The first local military treatment facility with rehabilitation services may provide a physical therapist and a physical therapy assistant as consultants to oversee the gym-based reconditioning program level I. The physical therapist can assist/coordinate training efforts with the RPL.
The medical platoon leader is the RPL, and the medical platoon sergeant is the assistant RPL or assistant reconditioning program leader (ARPL). If this is not possible, the RPL and the ARPL should be chosen based on the following criteria:
- Thorough understanding of the Army’s PRT program.
- Ability to instruct all activities.
- Understanding of regulations that govern profiling (AR 40-501, Standards of Medical Fitness).
- Ability to adapt activities to profiled Soldiers.
- Ability to effectively interact with medical personnel to ensure that Soldiers are fully capable of returning to the unit PRT program.
It is recommended that each company in the battalion should provide an NCO to assist the RPL on a daily basis. These NCOs should meet criteria mentioned above for the ARPL. In addition, training sessions should be provided on a quarterly basis by the physical therapist and/or physical therapy assistant to ensure proper supervision and optimal safety practices are observed. Trained NCOs will provide supervision and group instruction to Soldiers in the reconditioning program. To meet supervision requirements, at least two NCOs per company should be trained in the conduct and supervision of the reconditioning program.
Units should ensure adequate space and equipment are provided for the reconditioning program to accommodate STM and ETM drills. The reconditioning program is best executed at the brigade or installation fitness facilities. Because lower extremity injuries prevent many Soldiers from running activities, it is essential to have an adequate number of ETMs that offer cardio-respiratory conditioning while limiting weight-bearing stress to the body. Examples are cycle ergometers, steppers, elliptical machines, rowing machines, and treadmills. Treadmills are full weight bearing machines and are most appropriate for Soldiers cleared by medical personnel to begin a walk-to-run progression. Of these machines, cycle ergometers offer the most body weight support.
Pool activities such as swimming or deep-water running can eliminate weight-bearing stress. All Soldiers who are recovering from surgery or have open wounds will receive a physician’s clearance before entering the swimming pool. Swimming laps, aqua-jogging, and aquatic exercises are excellent ways to maintain or improve cardio-respiratory fitness without putting undue stress on joints and bones. Limitations to one leg or one arm are minimal deficits in a pool environment. Kick board workouts or upper body workouts allow for strenuous activity with minimal risk of re-injury to an affected limb. If staffing is adequate, specialized aquatics programs may be implemented to work on water aerobics or deep-water running programs for non-swimmers. It is important to plan activities that keep everyone active during group pool sessions. Even if a regular pool program is not practical, an occasional trip to the pool may be scheduled to break up the routine and provide cross-training.
Units that must rely on installation or shared facilities should make arrangements to ensure that space and STM/ETM equipment are available during the time dedicated to the reconditioning program. This may require policies that restrict the use of these facilities to only reconditioning programs. Leaders might need to schedule reconditioning outside typical PRT times such as after 0800 or before 1600 to best achieve dedicated access to gym space and equipment.
The reconditioning program is the battalion commander’s and command sergeant’s major program. A well-run program will assist force reconstitution efforts. The success of the program is dependent on the priority placed on it from the top down. Company commanders and first sergeants must care enough about the program to ensure NCO support.
The brigade surgeon and battalion medical officers should maintain constant awareness of the program. A medical officer with a background in rehabilitation should act as the installation medical consultant for reconditioning programs. The primary responsibility of the medical consultant is to act as a liaison or advocate for RPLs. The medical consultant should also provide training for the RPLs, ARPLs, and unit reconditioning NCOs. Figure 6-4 shows rehabilitation and reconditioning responsibilities.
Figure 6-4. Rehabilitation and reconditioning responsibilities
Trainers for the reconditioning program must possess the same knowledge of the program that the RPL have and must have additional education in exercise science. For this reason a physical therapist or a physical therapy assistant is well suited for the role. The following outline should be used when developing training for this program:
- STM Orientation
- Equipment familiarization: purpose, technique, safety.
- Etiquette: observe posted rules, replace all weights and equipment to original positions, and wipe down all surfaces after use.
- ETM Orientation
- Equipment familiarization: purpose, technique, safety.
- Etiquette: observe posted rules, replace equipment to original position, and wipe down all surfaces after use.
- Reconditioning Session Orientation
- Preparation: increase heart rate, muscle temperature to prepare the body for more vigorous activity.
- Activity: provide neural adaptation and improve strength, endurance, and mobility.
- Recovery: gradually return to resting heart rate (below 100 beats per minute) and bring body safely back to pre-exercise state.
- Level I (Gym-Based) Reconditioning Objectives
- Prevent de-conditioning.
- Work within profile limitations.
- Restore functional strength, endurance, and mobility.
- Avoid injury or re-injury.
- Transition to level II reconditioning.
- Level II Reconditioning Objectives
- Progress to pre-injury level of fitness.
- Avoid injury or re-injury.
- Transition to unit PRT.
PROFILES AND RECOVERY PERIODS
Soldiers in the reconditioning program will be on a physical profile or in the authorized recovery period from a temporary profile. Commanders may assign Soldiers with a permanent profile to the reconditioning program or allow them to remain in unit PRT. Soldiers on convalescence leave may be exempted from reconditioning at the discretion of the profiling medical officer. In no case can a Soldier carry a temporary profile that has been extended for more than 12 months without positive action taken to correct the problem or effect other appropriate disposition according to a military medical review board. Once a profile is lifted, the Soldier must be given twice the time of the temporary profile (but not more than 90 days) to train for the APFT. It is not a requirement to take an APFT after the recovery period if a Soldier is not due to take the semi-annual test. Refer to AR 350-1 and Appendix A of this FM for APFT policy and procedures. The RPL follows the medical guidance on the profile for Soldiers on profile. If there are any questions about the limitations of the profile, the RPL will contact the medical officer for clarification. Once a profile has expired, Soldiers will remain in the reconditioning program until they have met transition criteria to return to unit PRT activities. During this period, the RPL/ARPL, and unit reconditioning NCOs will reinforce the precise execution of PRT activities with each Soldier in small groups or individually. See Figures 6-2 and 6-3 for transition criteria to move from level I to level II or return to unit PRT.
Soldiers with permanent profiles that do not allow them to meet all reconditioning exit criteria may return to unit PRT once they demonstrate proficiency at all non-profiled activities. For example, a Soldier whose permanent profile only prohibits running would not be in the reconditioning program. Rather, he would do PRT with the unit and perform all activities except running. The Soldier in this example would walk or use ETMs when PRT activities call for sustained or speed running. When a permanent profile is so restrictive that the Soldier is unable to perform several PRT activities, the commander may direct the Soldier to the reconditioning program. This scenario is more likely to occur with Soldiers who are awaiting medical boarding procedures. For less clearly defined cases, the commander can solicit input from the battalion medical officer or brigade surgeon.
Progressing injured Soldiers to a “return-to-duty” level of fitness is the goal of any reconditioning program. There are two possible pitfalls to exercise progression. First, if the exercise progression is too rapid it may aggravate the injury, resulting in a further delay to recovery. Second, if the exercise progression is too slow it risks general deconditioning and a loss of effectiveness when returned to duty. A gap between recovery fitness and unit expectations may also cause undue physical and psychological stress. To assist the RPL/ARPL in decisionmaking regarding exercise progression, the following recommendations are made:
- Soldiers on profile will have specific limitations as defined by their DD Form 689 or DA Form 3349. These limits will be strictly adhered to.
- Communication with the profile writer is encouraged if a Soldier is clearly improving faster than written limits allow. There may be a reason that is not obvious for the slow progression. If there is no clear reason to limit the progression, instruct the Soldier to get a new profile that reflects communication with the health care provider. A written request is preferable to relying on the individual’s memory for this.
- Limitations that are in place for a given injury may not affect other areas. A case of tendonitis in the right shoulder should not affect the ability to do leg presses or ride a stationary cycle. Get a clear understanding from the Soldier of what they can and cannot do. Do not read between the lines of the profile. Once again, contact the profile writer if clarification is needed.
- Maintain an exercise workout log to track progress of each individual who will require more than two weeks of gym reconditioning. When a profile expires, work with unit leaders to ensure the recovery period is used for reconditioning until the Soldier can meet the criteria to re-enter unit PRT.